Medical associations, patient advocates, public health organizations and health systems are asking federal and state help to address the growing number of psychiatric patients seeking help. care in hospital emergency departments.
Patients are being kept in emergency departments for months as they await psychiatric beds. Many outpatient referral partners have reduced or are also facing staffing difficulties. The patient burden is straining ill-equipped hospitals, taxing already overcrowded staff and delaying care.
The system is being fractured in a demonstration of the systemic failures of mental health safety nets, the American College of Emergency Physicians and 30 other industry groups wrote in a letter. letter sent to the White House on Wednesday. Dr Christopher Kang, president of emergency physicians, said: “Without short- and long-term legal and regulatory measures, mental health care will continue to decline amid COVID cases. -19 surge, flu season and respiratory syncytial virus outbreaks.
“The system is at a breaking point. The mental health crisis is equivalent to [COVID-19] Kang said. “Everyone across the industry needs to work together. Otherwise, there will be irreparable harms.”
Health system operators and industry groups are campaigning for higher Medicaid reimbursement rates, relaxation of medical malpractice laws and broader scope of practice, among other potential solutions.
“There is no single magic bullet,” Kang said.
new normal
Health systems are scrambling to find alternatives as emergency department stays for psychiatric patients increase.
In Massachusetts, half of all psychiatric patients who visit emergency departments have been there for at least 12 hours as of June, according to data from the Massachusetts Health Policy Commission and the block’s Center for Health Information and Analysis. common prosperity. This is up from 38% in January 2020.
“Being able to connect those patients to an environment better suited for behavioral health care—not the emergency department—was a challenge,” said David Seltz, executive director of the committee. “We have an increased number of behavioral health care beds in Massachusetts, which is a huge advance. However, the challenge is being able to staff them.”
Many health systems are expanding inpatient psychiatric capacity to accommodate the increase in the number of psychiatric patients visiting their emergency departments. But they are limited by a shortage of mental health professionals and a shrinking outpatient referral network.
For example, Massachusetts General Hospital in Boston had to expand to accommodate the growing number of children and adults coming to the emergency department for mental health care. The facility has replaced the six-bed psychiatric ward with the 20-bed ward, but that remains. said executives often not enough.
Northwell Health, a New Hyde Park, New York-based nonprofit with 21 hospitals, has been trying to redirect patients to urgent care facilities with staff members providing health care services. mental health. Similar to other health systems, Northwell Health is integrating mental health services into primary care visits. CEO Michael Dowling said he is also trying to raise money for an adolescent mental health facility to supplement their children’s hospital.
“Our overall infrastructure for mental health is lacking. Capacity is lacking, there is a shortage of staff and that should be the main focus for all of us,” Dowling said. “It’s much worse now than it was before. Teen work is an area we’re really focusing on.”
In Wisconsin, Children’s Wisconsin in Milwaukee, Glendale-based Ascension Wisconsin, Milwaukee’s Froedtert Health and Downers Grove, Illinois-based Advocate Aurora Health entered a joint venture with Milwaukee County to open an 18-dollar psychiatric emergency facility million dollars in September.
Behavioral health services used to be less focused. The county covers half the cost and each health system contributes 12.5%. Joy Tapper, chief executive officer of the Milwaukee Health Care Partnership, a public-private alliance that promotes access to healthcare for low-income and underserved patients, said the emergency department has the capacity Can accommodate about 25 adults and 10 children.
Tapper estimates the new facility can handle 8,000 to 10,000 patients a year. She said there are six licensed inpatient beds, but they are used to stabilize patients and prepare for their transfer to other facilities.
The Milwaukee Center, although more cost-effective than hospital emergency departments, was forecasting an annual operating loss of $12 to $13 million because reimbursements for the majority of the Medicaid population did not. keep up with care costs, says Tapper. Higher capacity cases and staffing shortages add to the tension, she said.
“We are seeing significant capacity constraints in Milwaukee County and across our state for general inpatient beds for both voluntary and involuntary patients,” said Tapper. “This mental health emergency center is part of a broader redesign … focused on prevention and early intervention in the community.”
Tapper said Milwaukee County strives to develop its program for mobile crisis groups, which is deployed to reduce escalation and connect patients to care before they reach the emergency department. The county wants to combine crisis teams with law enforcement, she said, to build more behavioral health crisis centers, short-term stays, and place crisis staff in other crisis centers. clinic without appointment.
Treating children with behavioral health problems adds more challenges. Many of those patients are not in the emergency department but have nowhere else to go. Families are overwhelmed.
Dr. James Rachal, medical director of behavioral health at Charlotte, North Carolina-based Atrium Health, said there are also more behavioral disorders when children feel bored in undesigned settings. for them.
“If you have depression, have insurance, those people can actually find a bed pretty easily,” says Rachal. “Those are patients with more complex behavior and those who don’t have a source of pay…[who] should not be in the emergency room. They should be in the community, but there’s just no housing for them. “
This condition contributes to employee burnout and, in some cases, injury. Providers are pushing for more rest beds or urgent care sites that can accommodate overnight stays.
In the long run, Rachal said, more groups or foster homes are needed, plus better therapeutic services up front. Several years ago, Atrium Health launched a program to help young patients get through their first psychotic episode. Service providers work with patients and their families to help them continue working, attending school and/or building social relationships, which is difficult but doable, he said. with appropriate support.
Find the fix
Health system operators and industry groups want regulators and legislators to consider loosening regulations, encouraging partnerships, and expanding funding for graduate medical education.
Federal torture laws may be amended in certain circumstances to limit service providers’ liability, Kang said. For example, physician assistants could be at legal risk if they try to resuscitate a psychiatric patient in a waiting room, he said.
Regulators could relax the scope of practice for certain behavioral health care providers and allow them to treat patients without physician supervision, Kang said. “We need to find more partners and promote areas like social work.”
Monument Health, a five-hospital system based in Rapid City, South Dakota, has a 54-bed behavioral health hospital that practically fills rooms every day because it is one of the only facilities in type in its five-state area, CEO Paulette Davidson said.
The health system has developed a public-private partnership with county officials to build a 16-bed crisis stabilization unit. Law enforcement officers can bring someone in crisis to this facility, where they can stay up to five nights, instead of going to the emergency department.
“We are seeing more children, adolescents, and adults seek acute mental health services in our emergency rooms, particularly as a result of the impact,” Davidson said. of the pandemic. One in four patients, she said, has mental health problems. The government should encourage other public-private business ventures, she said.
Executives say more and more medical students need to pursue mental health careers to meet demand. Medicare pays teaching hospitals to offset the cost of inpatient training through graduate medical training funding. Typically, Medicare limits the number of residents it will fund per hospital based on the number of residents it funded in 1996.
According to Marty Bonick, president and chief executive officer of Ardent Health Services, the Nashville, Medicare-based 30-hospital system should remove those limits on mental health providers. . Tennessee. “There is a need to address physician limitations on medical graduate training programs,” he said.
Because Medicaid pays for most mental health services, reimbursement rates need to go up, Dowling said. “We built a new psychiatric hospital a few years ago, but the reimbursement was not enough so we had to cross-subsidize,” he said. “If we’re going to get answers to mental health, we need to do something about Medicaid reimbursement.”
